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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 11 of 11 Results
Goldman E, Sarkar U, Kessell E, et al. Ann Intern Med. 2014;161:472-81.
Readmissions and adverse events after discharge are a continued patient safety problem, as evidenced by the fact that more than 2500 hospitals have been penalized by the Centers for Medicare and Medicaid Services due to excessive readmission rates. Comprehensive programs such as Project RED and the Care Transitions Intervention have successfully prevented readmissions by using a dedicated transition provider (usually a nurse) who contacts the patient before and after discharge and helps coordinate care. This randomized controlled trial, conducted in an urban safety net hospital, found that such an approach did not reduce 30-day readmission rates—and may have increased postdischarge emergency department visits—compared with usual discharge care for a group of elderly, ethnically, and linguistically diverse patients with low health literacy. The study findings reinforce the importance of customized, patient-centered discharge approaches and highlight barriers to generalizing interventions to improve safety across sites of care and patient populations. These challenges are explored further in an AHRQ WebM&M interview with Dr. Eric Coleman, a pioneer in the field of care transitions and a recipient of a MacArthur Award.
Moy NY, Lee SJ, Chan T, et al. Jt Comm J Qual Patient Saf. 2014;40:219-227.
This quality improvement evaluation found that a structured inpatient-to-outpatient handoff tool in the electronic health record was successfully implemented and improved the timeliness of communication, a key step in preventing postdischarge adverse events.
Quirk M, Mazor KM, Haley H-L, et al. Patient Educ Couns. 2008;72:359-366.
This study conducted patient focus groups and video simulated scenarios to highlight and characterize physician behaviors around caring. Interestingly, the same behaviors that were interpreted as caring by some were viewed as uncaring by others.
Auerbach AD, Landefeld S, Shojania KG. N Engl J Med. 2007;357:608-13.
Since the publication of the Institute of Medicine's influential To Err Is Human report in 1999, clinicians and policymakers have embarked on an unprecedented quest to improve patient safety and the quality of health care. While some successes have been achieved, the best methods of improving care remain uncertain, and tension exists between those advocating for rapid dissemination of innovative strategies and those calling for evaluation of such strategies via clinical trials before dissemination. In this commentary, the authors outline arguments supporting and opposing each approach. They conclude that quality improvement interventions should be held to the same standards for determining effectiveness as other medical therapies, and use examples of recent patient safety interventions to illustrate the possible unintended consequences of ineffective initiatives.
Mazor KM, Reed G, Yood RA, et al. J Gen Intern Med. 2006;21:704-10.
This study concluded that full disclosure either has a positive effect or no effect on the way patients respond to medical errors. Investigators asked more than 400 patients to watch video scenarios and self-report on whether they would change physicians or seek legal advice if in those situations themselves. Participants also described their emotions and satisfaction levels, which varied depending on the clinical outcome presented, but findings supported the notion that nondisclosure has a negative impact on both. Overall, this study adds to the existing literature that advocates for full disclosure, supporting the argument that it fails to increase the risk of negative consequences for physicians. These researchers have previously discussed the teaching of medical errors, the factors influencing preceptors' responses to medical errors, and the factors that influence how students and residents learn from errors.
Fischer M, Mazor KM, Baril JL, et al. J Gen Intern Med. 2006;21:419-23.
Investigators conducted and analyzed nearly 60 structured interviews with medical trainees and categorized the factors that influenced their learning from errors. These factors were grouped as topic areas, which included awareness of error, factors influencing learner response (eg, personality, hidden curriculum), types of responses reported (eg, emotional, cognitive), and formal teaching. The authors discuss recommendations and specific educational methods that may promote improved learning from errors for trainees. A past study discussed one of these methods, Morbidity and Mortality Conferences, as a place to discuss medical errors with an educational focus.
Pierluissi E, Fischer M, Campbell AR, et al. JAMA. 2003;290:2838-2842.
Traditional morbidity and mortality conferences were designed to focus on educational opportunities to learn from an error or adverse event. This study examined how frequently such conferences actually fulfilled their mission by observing more than 330 of them in both internal medicine and surgery. Investigators discovered that internal medicine conferences involved more lengthy case presentations and discussions, more time listening to invited speakers, and less time in audience discussion. Surgery conferences more frequently presented errors and adverse events and also attributed errors to a particular cause. The authors discuss the lost opportunity for learning and the potential for closing such gaps with improved conference facilitation and an emphasis on using specific language and modeling directed towards system improvement. AHRQ WebM&M offers an online version of such a conference with presentation of cases and expert commentaries discussing relevant safety issues.